Monday, 7 January 2013

MALARIA: Several articles from Professor Brieger

The 13th meeting of the RBM HWG is taking place inDakar, Senegal this week. Some thoughts about the. Current status of malaria programs emerged from member experiences and are shared here.

Since the cancellation of the Global Fund Round 11 may have been denied around one billion dollars annually. If funding does not fully resume until 2014, we could be looking at nearly $3B loss.

In the meantime there is need to help countries spent what remains most efficiently. Effort to secure approval for phase two renewal of existing grants is a priority.

Some countries may have many donor partners but still face problems due to lack of coordination. Problems come when countries do not budget for major activities likely implementation of LLIN (net) campaigns. Procurement and supply management problems persist. Stock-outs are the resulting “disease” but we need to find the root causes.

Not all partners bring funds and commodities, but their input is still important. For example Peace Corps has been making important contributions in advocacy and community education.

When there are funding gaps we need to document the impact. Lives may be lost. Advocacy is needed using country case studies.

As malaria prevalence reduces there is still a possibility of outbreaks, especially in context if cross border situations. Better epidemic response planning is needed with full collaboration of neighboring countries. The challenge is that funding is still country based.

Vigilance is needed to determine how the new Global Fund financing processes will affect malaria prospects.

Issue 204 of the Global Fund Observer explains efforts to clarify funding challenges with the Ugandan malaria grant from the Global Fund. Their posting is shared below to increase access to this information. The financial problems have extended over several years, and GFO provides links to its previous articles on the problem, of which putting money into personal bank accounts was just one example.

…NEWS: Uganda and the Global Fund to strengthen control and financial oversight of anti-malaria programmes: Global Fund insists on refund of ineligible expenses: PR told to stop transfers of malaria programme funds to personal bank accounts

The Global Fund and Uganda’s Ministry of Health are implementing a plan to safeguard Fund disbursements in the country following concerns over possible mismanagement of a $51 million grant to support antimalarial bednet distribution. The principal recipient (PR) for the grant was the Ministry of Finance, but the implementing entity was the Ministry of Health (MOH).

The Fund said in a statement that options to strengthen financial oversight and management to mitigate the risk of fraud are also being discussed.

The statement follows a review by the local fund agent, PriceWaterhouseCoopers Limited Uganda, which was commissioned by the Global Fund. The purpose of the review was to assess part of anti-malaria support programmes which involved the procurement and distribution of over seven million insecticide-treated nets to pregnant women and mothers with young children. As a result of the findings from this review, the Global Fund asked the LFA to expand its review even further.

Meanwhile, Uganda’s MOH carried out an internal audit to verify expenditures and address the internal control weaknesses.

The Fund said in the statement that it instructed the PR to discontinue transfers to individual personal bank accounts of funds intended for programme implementation. The Fund has also warned Uganda that it will seek a refund of all improper payments related to the $51 million grant for supply of anti-malarial bednets, and will insist on appropriate disciplinary action against anyone found to be involved.

Global Fund programmes in Uganda currently provide ARV treatment for 291,000 people and have distributed 7.7 million insecticide treated nets. According to the country’s Malaria Control Strategic Plan, malaria kills between 70,000 and 100,000 people in Uganda annually.

A detailed account of the genesis of the problems facing Global Fund grants in Uganda can be found in GFO issues 90, 103, 113 and 125. [This article was first posted on GFO Live on 21 November 2012.] To comment on this article at the GFO website, click here.

Articles in The Lancet have reminded us of the seriousness of the global problem of preterm births which lead to 1.1 million infant deaths annually and is the second biggest cause of child deaths (those below 5 years old) after pneumonia. With over 11% of the world’s babies being “born too soon“, this is a problem of global magnitude.

Even higher income countries are affected, though in some instances it is a problem of their own making - preterm elective caesarian operations, multiple ovaries in assisted reproduction. Specifically for low/middle income and tropical countries the following was observed: “There are other preventive interventions, ranging from birth spacing to treating maternal infection, notably malaria, HIV, and syphilis, or improving nutrition, which are highly relevant for low-income and middle income countries.”

In her review of malaria in pregnancy Ruth Lagerberg observed that, “Adverse consequences of malarial infection during pregnancy include an increased risk of spontaneous abortion, preterm delivery, LBW, a two-fold increase in the risk for stillbirth regardless of parity, and congenital infection.”

Continued research has led WHO to recently recommended increase in the number of doses of IPTp in moderate to high endemic countries to receiving a dose at each ANC visit after quickening.

Malaria treatment should also be in the mix of antenatal interventions. Access to early diagnosis and treatment of malaria among refugees along the Thai-Burmese border was found to be a factor in decreasing low birth weight and prematurity.

The argument has always been made that since most pregnant women in malaria endemic areas of Africa attend antenatal care, it should be possible to reach them with malaria prevention and treatment interventions. Unfortunately coverage of malaria control measures for pregnant women remains low showing that health systems are not working for pregnant women. Greater priority is therefore needed on this neglected portion of the population at risk from malaria.

We are nowhere near eradicating malaria with hundreds of thousands of cases annually throughout the world. It reappears in Greece, and in subclinical form stymies surveillance efforts in the Solomon Islands. But eventually we will close in on this parasite. What can we learn from eradication efforts of another scourge, polio?

Recently the Express Tribune published an article that provided some shock not only in Pakistan, where the issue was detected, but throughout the polio eradication community. “The Prime Minister’s polio cell, the World Health Organisation (WHO), and the United Nations Children’s Fund (UNICEF) confirmed … a newly-found strain of the polio virus.”

The technical reason for the new stain was explained by the international health agencies: cVDPV cases that cause type 2 poliovirus mutate and attain a form that can cause paralysis after passing through multiple children in environments with substandard sanitation. Fortunately polio associated with vaccines is extremely rare, but a more damning administrative explanation of why this may have happened in Pakistan is “poor routine immunization coverage” that enabled these mutations to occur.

Administrative problems include poor scheduling of the current immunization round during a sacred religious period resulted in four districts not participating, but on top of this was a more pressing problem, “the global shortage of the oral polio vaccines especially as anti-polio campaigns are increasing .” This calls into question the upcoming second round of immunization in December. The problem is persistent since it was reported earlier this year that, “Polio coverage (in Pakistan) remained sub-optimal during the past year in Islamabad, as revealed by an independent evaluation report on the post-polio campaign conducted by the World Health Organization.”

Four endemic countries remain as seen in the graph, and Pakistan’s performance to date is actually better than some of the others, but the situation is volatile, as is the civil/political situation in the remaining affected countries. Interestingly, another eradication-targeted disease, Guinea Worm, was down to 1058 cases in 2011 and remains in only 4 countries, but this is 17 years after the initial date set for its eradication.

Polio and Guinea Worm offer malaria some lessons for the present in countries approaching pre-elimination now and those who will hopefully join them over the next decade (if global funding levels are maintained). One lessons is that surveillance is an active part of current polio eradication efforts, otherwise these reports on progress and its challenges would not be published. But the key lesson is that regardless of the effectiveness of the technical intervention (e.g. a vaccine), deployment of the technical intervention is subject to human, administrative, managerial and social complications.

Polio focuses on a vaccine; malaria has treatment medicines, preventive medicines, insecticide sprays, treated bednets, diagnostic tests, and maybe also one day an effective vaccine. It is not too early to plan on how to coordinate all this into achieving effective disease elimination, nationally, regionally and globally.

The Neglected Tropical Diseases (NTDs) community convened at the World Bank for a 2-day conference tagged “Uniting to Combat NTDs: Translating the London Declaration into Action” on November 17 – 18, 2012 in Washington DC. The objective was to provide a forum where all stakeholders in the fight against NTDs can identify the priorities, discuss the challenges and suggest strategies towards achieving the World Health Organization’s (WHO) targets to control and eliminate at least 10 NTDs by 2020.

Leveraging on the London Declaration of January 30, 2012 by leading pharmaceutical companies, donor agencies and non-governmental organizations (NGOs), to supply the drugs required for preventive chemotherapy (PCT) and the treatment of NTDs, the participants identified three priority areas necessary for the actualization of the WHO’s 2020 targets:

Bridging the estimated $US 4.7 billion funding gap by sustaining international commitments and increased domestic funding for NTDs by endemic country governments.

Building the human resource capacity and health infrastructure at the country-level to effectively absorb the increased supply of drugs, and for the scale-up of delivery services.

Effective integration of intervention programs and incorporation of water and sanitation interventions (WASH), to complement the mass drug administration, and intensified disease management of NTDs.

It was encouraged that Malaria & NTDs (Lymphatic Filariasis & Dengue fever) programs should integrate their services, because the scale-up of vector control interventions (LLINs) will benefit the populations served by both programs. However, a critical barrier limiting this collaboration is the suspicion by malaria programs that NTDs managers intend to leverage on the availability of more funding for malaria programs, to achieve specific NTDs targets.

I recommend that program managers for malaria and NTDs (LF & Dengue fever) should adopt the partnerships and four One’s approach, which has contributed greatly to the success of WHO’s African Program for Onchocerciasis Control(APOC) –

The Corporate Alliance on Malaria in Africa announces a Member Meeting that will take place on December 3, 2012 from 10 am – 4 pm in Houston, Texas. They have shared their invitation with us to let interested colleagues know how to take part.

The Corporate Alliance on Malaria in Africa (CAMA) is a unique coalition of companies that share a vision to reduce the incidence of malaria by promoting private sector cooperation in sub-Saharan Africa. Founded by Marathon Oil in 2007, CAMA serves as a platform for private sector collaboration with country governments and other major stakeholders in the global response against malaria.

CAMA’s three principal objectives include -

building country-level capacity for effective malaria control and its eventual elimination;

providing a forum to exchange knowledge and current best practices in malaria control; and

facilitating the establishment of effective multi-sector partnerships to increase the scale and impact of malaria control interventions.

GBCHealth is the implementing partner and secretariat of CAMA.A special Member Meeting will be held Monday, December 3, 2012, in Houston, Texas, to discuss the accomplishments of the past year and to develop the CAMA engagement strategy for 2013. As CAMA transitions into a fully integrated GBCHealth flagship initiative, this CAMA member meeting will be open to all current and prospective GBCHealth members interested in contributing to global malaria efforts.

The meeting will cover the importance of social and behavioral change programs for controlling malaria at the country level and provide a great networking opportunity for companies to meet key malaria stakeholders from academia, business and non-profits.

Current efforts to reduce burden of uncomplicated malaria among children under-five years old in low income countries is undermined by presumptive treatment of the disease. Proper and early diagnosis of malaria using Rapid Diagnostic Tests (RDTs) in integrated case management may restrict inappropriate use of anti-malarial medicines to children.

This observational study documented diagnostic and treatment patterns for febrile illness management in local government clinics in Akwa Ibom State, Nigeria before and after introduction of RDTs. Audit of outpatient client records before and after RDT introduction was conducted in six primary health care facilities in two Local Government Areas, Onna and Ibeno by three trained nurses.

A total of 1003 children presented with fever prior to RDT introduction, and 90.3% were presumptively treated with anti-malarial medicines; 66.1% also received antibiotics. After the introduction RDTs, records of 800 children who presented with fever were reviewed and 90.9% were tested using RDTs with 41.5% of 720 being confirmed cases of malaria. Of children with positive RDTs results 95.6 received anti-malarial medicines. Among those with RDTs negative results 22.9% received anti-malarial medicines while 88.7% got antibiotics.

The study supports the use of RDTs for febrile illness testing to aid adherence of health workers to integrated child treatment protocols. Though there is still a gap in prescribing behavior, this can be corrected through supervision and ongoing performance quality tools.

Village/ Mobile Malaria Workers (VMWs/MMWs) are a critical component in Cambodia’s national strategy to reduce malaria morbidity and mortality. Since 2004, VMWs have been providing free malaria diagnosis and treatment using Rapid Diagnostic Tests and Artemisinin-based Combination Therapies in hard-to-reach villages (>5km from closest health facility).

VMWs play a key role in control and prevention, diagnosis and treatment of malaria as well as in delivering behavioral change communication (BCC) interventions to this target population. To evaluate the implementation of these activities performed by VMW/MMWs, a quantitative and qualitative assessment was conducted in 5 provinces of western Cambodia in order to:

(i) understand job satisfaction of VMWs and MMWs vis-a-vis their roles and responsibilities;

(ii) assess their performance according to their job descriptions; and

(iii) gain insights into the challenges faced in delivery of diagnosis, treatment and health education activities to their communities.

A total of 196 VMWs/MMWs were surveyed in October 2011 using a combination of quantitative and qualitative methods. Triangulation of quantitative and qualitative data helped to gain a deeper understanding of the success factors of this intervention and the challenges faced in implementation.

Overall, levels of VMW performance were in line with the expected performance (80%); however, some performance gaps were identified in the areas of knowledge of malaria symptoms, treatment regimens, and key messages. In particular, there were low levels of practice of the recommended direct observed therapies (DOTs) approach for malaria treatment (especially for the second and third doses), reportedly caused by stock-outs, distance and transportation.

The national malaria program should aim to focus on improving knowledge of VMWs in order to address misconceptions and barriers to effective implementation of DOTs at community-levels. In addition to the findings, the tools developed, will potentially help the national program to come up with better indicators in the near future.

Findings from this evaluation are being used to inform planning of future activities and interventions such as DOT in a context where artemisinin drug resistance is a significant public health issue.

Efforts by the Zanzibar Ministry of Health to scale-up malaria prevention and treatment strategies, including intermittent preventive treatment for pregnant women (IPTp), have brought Zanzibar to the pre-elimination phase of malaria control. P. falciparum prevalence in the general population has been below 1% since 2008 and the diagnostic positivity rate among febrile patients was 1.2% in 2011.

Zanzibar implemented IPTp using sulfadoxine-pyrimethamine (SP) in 2004 when malaria prevalence exceeded 20%. While coverage among pregnant women is low (47% received two doses SP), the value of this intervention in low transmission settings remains uncertain. Few countries in Africa have confronted policy questions regarding timing of IPTp scale-down.

We designed a prospective observational study to estimate prevalence of placental malaria among pregnant women with no evidence of receiving any dose of SP for IPTp during pregnancy. From September 2011 to April 2012 we enrolled a convenience sample of pregnant women on day of delivery at six hospitals in Zanzibar (three in both Pemba and Unguja).

Birth weights for both deliveries were normal (>2500 g). Data collection will continue through the peak transmission season of May-July 2012. The very low prevalence of placental infection among women who received no IPTp raises policy questions regarding continuation of IPTp in Zanzibar. Alternative efforts to control malaria in pregnancy in Zanzibar, such as active case detection via regular screening and treatment during antenatal visits, should be evaluated.

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About Me

After service in the British SAS Regiment the author became a physician and then an orthopaedic surgeon.
He has held professorial positions in Canada, Vietnam and the United States, practiced and taught orthopaedic surgery in three continents and in several wars.
He has extensive experience as an expert witness in court. Somewhere along the way, time was found to operate a four hundred acre mixed farm, a one hundred seat restaurant and to obtain a licence as a flying instructor.
The author's books are available from bookstores, the publishers, or from on-line bookstores such as Amazon, Barnes and Noble, and Indigo/Chapters.
http://mclementhall.com